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PLEASE PILL OUr LRONLY A COMPLETELY TO AVOID DELAYS IN PROCEBSNG
TO THE INSPECTOR OF BUILDINGS:
This undsraipW hmW appl a for a permit to build a000lft to ttta kMowir>p
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No.
APPLICATION FOR
PERM TO
LOCATION
PERMIT GRANTED
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003r F BLKMPIGS
39 \
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_Applicant Information Please Print Legibly
Name (Business/orga ization(rnaivi u):
Address: f7�Li 9 ECM, a 5-
City/State/Zip: Lt DCPG EST�IZ Phone#: 564—5 7
G
Are you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with 1(') — 4. ❑ I am a general contractor and I 6 ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- .
listed on the attached sheet t 7• ® Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required] officers have exercised their 10.0 Electrical repairs or additions
3.Q I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.Q Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
•Any applicant that checks box#r must also fill out the section below showing their workers'compensation policy infommtion:
t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that Is providing workers'compensation Insurance for my employees Below is the policy andlob site .
information. / n
Insurance Company Name: N f/ l Aj S. C.D
Policy#or Self-ins. Litz #: /o &I D 9 4�L Expiration Date- 7
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
)f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby certify under th ains a/nd/penaties ojperjury that the Information provided above is true and correct
mature• //�( Date
?hone#: 7 (,,
Official use only. Do not write in this area,to be completed by city or town offxkL
City or Town: Per•mit/Llcense#
Issuing Authority(circle one):
1.Board of 13ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
4
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In a000rdaace With the/nvisina at Mt,c40 S 34r a candidan of your
Haiidins Ptrmit is that the dab& I lbw this Wars Shall be disposed
of is a peopedy licensed solid WUM dlapoaal facility as defined by MC.
Chapter lq 5150 A.
IU debris Will be disposed of in:
(Location of Facility)
SignaMm of Applicant
Date